ALS needed or no?

[chickj0434]

Call came in for chest pain. Bls responded with als behind. Pt was 50 year old female. No cardiac history, diabetes, and arthritis. Pt was complaining of upper chest pain 10 out of 10, neck pain and headache. Pt was not sweating, no trouble breathing, no nausea. Or stated pain was made worse when crew pressed on chest, she moved, or took a breath in. Pain started hours ago. Crew gave 324 mg of aspiring. Pain dropped down to 7. Would you call for als or transport patient and why.

 

[RocketMedic]

Depends a lot on where in the world you are (for example, if you're minutes away from a capable ED, it makes more sense to transport this potentially-urgent patient to the ED instead of waiting for ALS, because a BLS provider has no real way to diagnose or assess this patient); but in general terms, this is a patient that absolutely needs a thorough ALS assessment and potentially treatmetn.

You can't really make definitive assessments based on reproducible pain, particularly in a diabetic female population, nor will aspirin affect pain in a typical EMS timeframe (not to mention that it doesn't really work on pain anyway, this would be a textbook placebo effect). Pain relief from nitroglycerin would be more telling, but is still not definitive. In either event though, the answer is to transport this patient for labs, imaging and ECG.

 

[EpiEMS]

Would you call for als or transport patient and why.

These aren't mutually exclusive - you can always have the ALS unit intercept. Me, I'd likely start transporting, and have ALS meet me on the way.
Administering ASA doesn't seem unreasonable to me, given the chief complaint & comorbid factors.

 

[chickj0434]

Thanks for the response. Hospital was 5 min away and als was coming from a distance. I cancelled als and transported myself. Should have asked how far als was to dispatch and still asked for als so I'm kicking my self for that one

 

[EpiEMS]

Thanks for the response. Hospital was 5 min away and als was coming from a distance. I cancelled als and transported myself. Should have asked how far als was to dispatch and still asked for als so I'm kicking my self for that one

Hospital was the right call, then!

 

[RocketMedic]

ALS isn't going to do much that a hospital won't. The only *possible* difference is the chance of a clear-cut diagnosis and cath lab activation in the event of a STEMI, but don't beat yourself up over that, because many hospitals can actually handle that in-house and those that can't have transfer agreements and such.

 

[chickj0434]

ALS isn't going to do much that a hospital won't. The only *possible* difference is the chance of a clear-cut diagnosis and cath lab activation in the event of a STEMI, but don't beat yourself up over that, because many hospitals can actually handle that in-house and those that can't have transfer agreements and such.

Thank you. I just wish I called for als and checked with dispatch to see how far they were instead of making that assumption on my own

 

[Carlos Danger]

You can't really make definitive assessments based on reproducible pain, particularly in a diabetic female population, nor will aspirin affect pain in a typical EMS timeframe (not to mention that it doesn't really work on pain anyway, this would be a textbook placebo effect). Pain relief from nitroglycerin would be more telling, but is still not definitive. In either event though, the answer is to transport this patient for labs, imaging and ECG.

Aspirin doesn't work on pain?

 

[RocketMedic]

Aspirin doesn't work on pain?

Not in the timeframe of a typical EMS encounter, and not in the sense that it inhibits receptors...

 

[hometownmedic5]

Perception is one of the biggest pain relievers ever to exist; ie, if your patient was under the misguided notion that you were giving them ASA for their pain, they may have perceived a reduction in their pain(placebo affect) and reported the same to you. I once had a patient tell me they felt substantially better after the shot I gave them, that shot being a finger stick from a lancet for a CBG. It's all perception.

If your hospital was a legitimate five minutes away and your ALS was a legit ten+, your closest source of ALS was the hospital and you did the right thing; but since you didn't ask what the ETA of the medics was, you're guessing. Perhaps you guessed right, but next time make the radio call and get a real world ETA from the responding medics prior to making the decision. You'll be on much firmer ground in the event the call goes pear shaped and you have to answer questions.

 

[photog]

Or... you could have taken full set of vitals, collect history / anamnesis, do a 12-Lead ECG and start the iv line while waiting for ALS to arrive? And if the patient was hypertensive and ECG didn't show malign changes in the inferior leads, you could have given a few puffs of NTG spray while waiting. Then, after arrival of ALS, if it would've been a STEMI (or something other cardiac-related), the advanced treatment (morphine, plavix / brilique, klexane...) could have been started immediately, and transport as well.

 

[bakertaylor28]

Aspirin doesn't work on pain?

Pain isn't the reason we give aspirin in chest pain cases. We give aspirin mainly as a low-risk anti-platelet in chest pain cases, as it prevents clots from getting bigger in cases of MI and PE.

 

[hometownmedic5]

Or... you could have taken full set of vitals, collect history / anamnesis, do a 12-Lead ECG and start the iv line while waiting for ALS to arrive? And if the patient was hypertensive and ECG didn't show malign changes in the inferior leads, you could have given a few puffs of NTG spray while waiting. Then, after arrival of ALS, if it would've been a STEMI (or something other cardiac-related), the advanced treatment (morphine, plavix / brilique, klexane...) could have been started immediately, and transport as well.

It would certainly not be fair to assume that BLS protocols are that advanced everywhere, even if they are where you live. Most basics don't have monitors, IV therapy, or their own NTG; nor do they have the training to ascertain STEMI criteria. There are BLS ambulances out there that don't even have AED's...

 

[bakertaylor28]

Call came in for chest pain. Bls responded with als behind. Pt was 50 year old female. No cardiac history, diabetes, and arthritis. Pt was complaining of upper chest pain 10 out of 10, neck pain and headache. Pt was not sweating, no trouble breathing, no nausea. Or stated pain was made worse when crew pressed on chest, she moved, or took a breath in. Pain started hours ago. Crew gave 324 mg of aspiring. Pain dropped down to 7. Would you call for als or transport patient and why.

What about trauma? That sounds alot like bruised ribs. Conversely, it Could also be the beginnings of a Hiatial.

 

[bakertaylor28]

It would certainly not be fair to assume that BLS protocols are that advanced everywhere, even if they are where you live. Most basics don't have monitors, IV therapy, or their own NTG; nor do they have the training to ascertain STEMI criteria. There are BLS ambulances out there that don't even have AED's...

Aren't AED's considered a fundamental BLS skill these days? Would expect everyone to have 'em pretty much.

 

[photog]

There are BLS ambulances out there that don't even have AED's...

Why on earth are they called ambulances then? What I described or suggested is pretty much SOP with BLS ambulances around here.

 

[hometownmedic5]

Aren't AED's considered a fundamental BLS skill these days? Would expect everyone to have 'em pretty much.

I thought so too, but I was wrong. As some of our California friends here informed me, there are still "ambulances" Cali that are little more than first responder gurney vans. It took me awhile to get my head around it too...

Why on earth are they called ambulances then? What I described or suggested is completely SOP with BLS ambulances around here.

Yes, I understand that those protocols might apply in your area. I said almost exactly that in my post. I also said you shouldn't expect all areas to have anywhere near that level just because yours does. There are plenty of places where they're still playing early 90's EMS, if that...

 

[bakertaylor28]

I thought so too, but I was wrong. As some of our California friends here informed me, there are still "ambulances" Cali that are little more than first responder gurney vans. It took me awhile to get my head around it too...

Interesting. I was under the understanding and influence that they had started including AEDs as a required BLS skill in the National Registry Exams, and that they had been universally deployed in BLS units as a formal standard of care. Then again I can see that some places apparently aren't as on top of things. And I wouldn't expect that for CA either.

 

[EpiEMS]

AEDs as a required BLS skill in the National Registry Exams

They definitely are part of registry.

Inexplicably, LA County doesn't seem to require that "BLS" units carry AEDs. It really is nuts!

http://file.lacounty.gov/SDSInter/dhs/206307_710.pdf

Or... you could have taken full set of vitals, collect history / anamnesis, do a 12-Lead ECG and start the iv line while waiting for ALS to arrive? And if the patient was hypertensive and ECG didn't show malign changes in the inferior leads, you could have given a few puffs of NTG spray while waiting. Then, after arrival of ALS, if it would've been a STEMI (or something other cardiac-related), the advanced treatment (morphine, plavix / brilique, klexane...) could have been started immediately, and transport as well.

In the U.S., one of the main things that is seen as differentiating BLS care from ALS (or, perhaps, Intermediate Life Support) care is venipuncture & administration of medications via the IV route. Most U.S. BLS ambulances do not carry cardiac monitors and nitroglycerin, nor are most U.S. BLS providers permitted to administer non-patient prescribed nitro, or start IVs. For your reference, here's the national scope of practice document adopted in 2007 (more of a set of guidelines, really, because there is no "national" licensing body).

 

[Carlos Danger]

Not in the timeframe of a typical EMS encounter, and not in the sense that it inhibits receptors...

I agree about the onset time, but that wasn't the part of your post that I was responding to. I just wondered where you got the misinformation that aspirin "doesn't really work on pain anyway", or even that it doesn't work on receptors. It absolutely does both.